DISCUSSION
The present study assesses the impact of an education intervention in a PED on healthcare providers’ theoretical knowledge and practical skills about IT and how it varies during the study period. We observed that after an education intervention, theoretical and practical knowledge on IT improves among healthcare providers and it remains for at least six months.
Concerning the impact of the education intervention performed, scores of the theoretical questionnaire and practical skills improved globally and in all healthcare groups. These results are consistent with previous studies, which have been mainly performed with MIR14,15,18. Unlike other studies, we evaluated the impact twice after the education intervention: in the short (one month) and medium term (6 months). Globally, better scores were obtained in P3 with respect to P2, probably due to the fact that, after evaluation in P2, we explained and rectified mistakes. Therefore, this strategy validates the need of repeated training in order to acquire correct IT. Additionally, we observed a greater improvement in IT with space chamber and mouthpiece with respect to IT with space chamber and facemask secondary to scarce initial knowledge about the use of the former, which goes in parallel with the findings of previous studies19.
As a secondary endpoint, we evaluated IT theoretical knowledge and practical skills among healthcare providers. At baseline, we obtained global poor results in theoretical and practical skills. In line with our findings, Satambrogio et al found that the medium score in the evaluation of IT was 9.9 over a total score of 21 and that none of the participants answered correctly to all the theoretical questions7. Similarly, Spaggiari et al conducted a study in the PED, detecting that only 49% of participants did all the steps correctly in the practical examination and 34% almost perfectly12.
Regarding practical skills, the scores of IT with space chamber and mouthpiece were lower than when facemask was added. Likewise, Satambrogio et al found that healthcare professionals committed a lower number of errors in IT with space chamber and facemask7. We also analyzed specifically which steps were the best and worst performed. On one hand, up to 96.4% set-up the inhaler device correctly and 92.9% pressed the canister just once for each inhalation when performing IT with a space chamber and facemask. However, less than half of the participants (41.7%) awaited 30-60 seconds between inhalations. In contrast to our findings, Spaggiari et al found that the most mistaken step was shaking the canister before the next inhalation and patients’ position during IT12. On the other hand, the most forgotten step in IT with space chamber and mouthpiece was taking a deep exhalation before inhalation (75%) followed by exhaling slowly after inhalation (79.8%). Similar results were obtained in a systematic review by Plaza et al11.However, in other studies, the most frequent errors were not breath-holding after inhalation and not waiting a minute before the next inhalation7. These results are especially important, as identifying gaps in knowledge regarding proper IT is essential to impart continued education programs.
We also evaluated predictors of theoretical and practical knowledge at baseline. Regarding the theoretical questionnaire, MIR obtained better scores than nurses and nursing assistants. Both age and number of years of experience in PED were inversely related to these scores. However, in the multivariable analysis, only the laboral category influenced these results. This can be explained by the fact that, in our hospital, MIR follow a specific program in which they are trained in IT, hence, having better scores despite being younger and having fewer years of experience. Previous studies did not find differences between age or years of experience either7. With respect to practical skills, MIR obtained better results than nurses. In contrast, previous studies observed that nurses obtain higher scores than physicians. This finding has been attributed to scarce specific education to medical doctors on this subject due to the fact that nurses are the ones who usually conduct and teach IT6,7,12. Additionally, we obtained that asthmatic participants obtained higher scores in IT with space chamber and mouthpiece, as this technique is similar to IT in adults. Interestingly, they did not get better results in the theoretical questionnaire nor in IT with space chamber and facemask, as already reported by Madueño et al20.
Lastly, participants were highly satisfied after the education intervention. However, we cannot compare our results with other training programs due to the lack of studies regarding healthcare professionals satisfaction after an IT education intervention.
Prescription of MDI should always be associated with proper information and training of the use of the specific inhaler prescribed21,22. However, our study corroborates the lack of knowledge and incorrect IT among healthcare professionals, hampering the possibility of teaching IT correctly. Unlike other studies, our study sheds light to this situation by providing an intervention which improves healthcare professionals’ IT knowledge and practical skills in the short and medium term. Additionally, it proved useful at introducing IT with space chamber with mouthpiece, allowing healthcare professionals in the PED to teach IT according to the patient’s needs. Enhancing correct IT training in the PED can improve asthma control and, therefore, patients’ adherence to treatment23.
Our study should be considered in light of its limitations. Due to the unicentric characteristics of our study, the impact of the education intervention is limited. However, it could be extended to other centers in order to homogenize knowledge and practical skills of healthcare professionals locally or nationally. Global results could have been influenced by stress, as participants were recruited during their working shift. Additionally, results could have been influenced by the fact of being observed and knowing the study was underway (Hawthorne effect). Due to the impact of COVID pandemic on PED visits, we have not been able to measure clinical outcomes such as hospital admission or return visits. The number of PED visits have reduced drastically in consequence of pandemic, having attended 50% fewer patients for an acute asthma episode with respect to prepandemic situation. Additionally, admission rates have increased from an 11.8% in 2019 to 15% in 2020. This could be due to the fact that only children with moderate and severe asthma episodes consulted PED during pandemic. This fact implies an important bias upon admission rates and in consequence, we considered admission rates not to be a useful outcome to measure the impact of the education intervention performed in our study. Lastly, the number of participants in each phase varies, due to different circumstances such as vacation periods (phase 2 was performed in summer) and to working shifts and inpatient redistribution (specially nurses and nursing assistants) due to pandemic situation.